2012 13 Application for Disbursement by HC12062611414

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									Application for Disbursement of Miss Louisiana Scholarship Funds
                                              2012-2013

Completion of this form and the attachment of the necessary documentation are required for the payment of
all scholarships.


CONTESTANT INFORMATION:


Application Date: ___________________________________________________________________

Contestant Name: ___________________________________________________________________

Address: __________________________________________________________________________

Phone & E-Mail: ___________________________________________________________________
                   (HOME)                        (CELL)            (EMAIL ADDRESS)

Social Security Number: ________________________________________________

Name of Local Title & Year: __________________________________________________________

Name of Pageant Director ____________________________________________________________



COLLEGE/UNIVERSITY INFORMATION:


College or University: ________________________________________________________________

Complete Address: _____________________________________________________________________

Name of Comptroller: ______________________________________________________________

Phone and E-Mail of Comptroller: ____________________________________________________
                                          (OFFICE)                           (EMAIL ADDRESS)

Student ID Number: __________________________________________________________________
THE FOLLOWING INFORMATION IS REQUIRED AND MUST BE ATTACHED TO THIS DOCUMENT IF
APPLICABLE TO YOUR REQUEST FOR SCHOLARSHIP FUNDS:

          LETTER OR EMAIL FROM CONTESTANT REQUESTING PAYMENT OF SCHOLARSHIP
          LETTER OR EMAIL FROM LOCAL PAGEANT DIRECTOR VERIFYING THAT ALL LOCAL SCHOLARSHIP
           MONIES HAVE BEEN EXHAUSTED
          ORIGINAL BILL OF SALE FOR COMPUTER AND/OR IPAD ALONG WITH ORIGINAL CREDIT CARD
           RECEIPT OR CANCELLED CHECK FRONT AND BACK
          FULLY EXECUTED LEASE AGREEMENT WITH CONTESTANT AS LEASEE
          COPY OF CURRENT SCHOOL SCHEDULE, NOT NEEDED FOR STUDENT LOAN PAYMENT
          COPY OF CURRENT TUITION BILL, NOT NEEDED FOR STUDENT LOAN PAYMENT
          IF FOR BOOK REIMBURSEMENT, NEED A COPY OF SYLLABUS /CLASS SCHEDULE
          OFFICIAL TRANSCRIPT, ONLY NEEDED FOR STUDENT LOAN PAYMENT
          CURRENT BILL FROM STUDENT LOAN LENDER, WHO OWNS YOUR BILL NOW, SHOWING PAYMENT
           ADDRESS, STUDENT’S NAME AND LOAN NUMBER ALONG WITH PROMISSORY NOTE(S)




Scholarship requests should be sent to:

             Miss Louisiana Scholarship Organization
             Attn: Connie Sullivan, Scholarship Chairman
             3016 North 12th Street
             West Monroe, LA 71291


I have read this document and understand that I must follow the instructions and rules/regulations for
disbursement of all scholarships. Please allow at least three weeks for processing.


________________________________________
SIGNATURE OF CONTESTANT


________________________________________
DATE


4/12

								
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